Case Report

Spontaneous spinal epidural hematoma of thoracic spine: a rare case report and review of literature

Abstract

Spontaneous spinal epidural hematoma is a Rare condition of Spinal cord compression, and emergent Decompressive surgery is strictly indicated. Early recognition, accurate diagnosis, and Rapid treatment may result in decreased morbidity and improved outcome. Here, we present a case of a 50-year-old man who sustained sudden onset of severe back pain, followed by progressive weakness and numbness over bilateral lower limbs. Magnetic resonance imaging of thoracic spine demonstrated an epidural mass extending from T6 through T8, causing spinal cord compression. Emergent decompressive surgery was performed, and epidural hema- toma was diagnosed postoperatively; the patient had significant improvement of neurologic deficits. The relevant literature is also reviewed.

Spontaneous spinal epidural hematoma (SSEH) is uncommon, and etiology remains obscure [1]. The typical symptom of SSEH is sudden onset of severe Back or neck pain, followed by symptoms and signs of rapidly evolving nerve root and spinal cord compression. The duration between symptom onset and accurate diagnosis is very important for SSEH because therapeutic outcome depends on the delay between diagnosis and Surgical decompression. Management of SSEH remains a challenge for physicians. Here, we report a case with SSEH of thoracic spine and reviewed the relevant literature.

A previously healthy 50-year-old man complained of sudden onset of severe back pain, followed by progressive weakness and numbness over bilateral lower limbs. On physical examination, paraplegia (muscle power scored as 0/5 in bilateral lower limbs), decreased sensation below the T10 dermatome, and incontinence of urine and stool were discovered. On neurologic examination, bilateral flexor plantar responses were present and deep tendon reflex in bilateral knees and ankle was increased. The laboratory examinations revealed no remarkable contribution. magnetic resonance images of thoracic spine demonstrated an epidural mass extending from T6 to T8, causing spinal cord compression (Fig. 1A and B). The mass

had a homogeneous isointensity to the spinal cord on T1-weighted imaging (T1WI) and hyperintensity on T2-weighted imaging (T2WI). After injection of gadolinium, the mass had peripheral enhancement (Fig. 1C). Based on the clinical presentation and imaging findings, an epidural hematoma of thoracic spine was highly suspected. He received emergent laminectomy of thoracic spine. On operation, an epidural hematoma was discovered and evacuated. Pathologic report revealed hemorrhage without neoplasm or vessel malformation. Postoperatively, his neurologic deficits recov- ered well.

Spontaneous spinal epidural hematoma is a rare spinal emergency in the emergent department and is composed of less than 1% of spinal space-occupying lesions [2]. Spontaneous spinal epidural hematoma accounts for 40% to 50% of spinal epidural hematomas [3]. The etiology of SSEH remains unknown and has been associated with coagulopathies, blood dyscrasias (leukemia or hemophilia), arteriovenous malformations, hemangiomas, thrombolytic therapy, cocaine use, and chiropractic spinal manipulation [1,4]. The sex ratio (male-female) is 1.5:1, and most SSEHs occur in patients between the ages of 50 and 80 years [5]. Although the exact pathogenesis of SSEH is unclear, bleeding from posterior epidural venous plexus is the most possible origin [6]. Normal activities or other maneuvers can cause fluctuations in the intrathoracic and intra-abdominal pressures, resulting in the rupture of delicate and valveless epidural venous plexus [4]. However, some researchers have considered an arterial source of bleeding that results from the disruption of a tortuous arterial plexus by traction on nerve roots [7].

The clinical presentations of SSEH are characteristic of sudden onset of severe back or neck pain around the involved vertebrae with radiating pain around the corresponding dermatomes, followed by signs and symptoms of spinal cord and/or nerve root compression [8]. The initial symptoms are usually vague, and the hematoma is difficult to identify until the patient has the symptom of cord compression hours or days after the onset of pain. The symptoms of spinal cord compression include ascending numbness, radicular par- esthesia, and progressive paraparesis [2]. There may be a long delay between the onset of symptom and the development of neurologic deficits. If there is a delay in treatment, progressive spinal compromise can lead to permanent neurologic deficits or even death [1].

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Fig. 1 Magnetic resonance imaging of thoracic spine. A, Sagittal T2WI revealed a predominantly isointensity posterior epidural mass extending from T6 to T8. B, Axial T2WI revealed the epidural mass located in the right-posterior aspect of the Spinal canal, compressing the spinal cord. C, After injection of gadolinium, sagittal T2WI revealed the peripheral enhancement.

In the past, computed tomographic myelography had been a good diagnostic method for SSEH; but computed tomographic myelography has been replaced by spinal MR imaging as the better diagnostic method nowadays [1,8]. The MR images of SSEH vary based on the clot, age, and oxygenation [9]. Within the first 24 hours after symptom onset, the hematoma appears as isointensity on T1WI and hyperintensity on T2WI. After 24 hours, it appears as a high signal on T1WI and as a low signal on T2WI. After injection of gadolinium, peripheral enhancement of lesion is mostly found and central enhancement is occasionally found [10].

Early Decompressive laminectomy with evacuation of hematoma is considered as the best treatment for SSEH [6]. However, nonoperative therapy may be justified if minimal neurologic deficits are presented. The outcome predomi- nantly depends on the level and extent of the lesion, severity of the neurologic deficits, and the interval between onset of symptom and surgical decompression.

In conclusion, it is very important for physicians to keep in mind the diagnosis of SSEH, especially when a patient has the presentation of sudden-onset back or neck pain followed by symptoms or signs of spinal cord compression. Urgent spinal MR imaging is essential to confirm the diagnosis, and decompressive laminectomy with evacuation of hematoma is strictly indicated. Early recognition, accurate diagnosis, and appropriate treatment may result in significant neurologic improvement and good outcomes.

Wei-Hsiu Liu MD Cheng-Ta Hsieh MD

Yung-Hsiao Chiang MD, PhD Guann-Juh Chen MD

Department of Neurological Surgery Tri-Service General Hospital National Defense Medical Center

Taipei 114, Taiwan, Republic of China E-mail address: [email protected]

doi:10.1016/j.ajem.2007.05.036

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